1 The Role of Process Improvement In Health Systems’ Design HSPH Stakeholders’ Advisory Board Meeting December 9-11, 2015 James Heiby, MD, MPH Medical Officer Global Health Bureau USAID

2 Traditional approaches have failed to address processes of care Inputs Outcomes Process Cote d’Ivoire PMTCT Standards developed Providers trained Drugs available Cote d’Ivoire PMTCT Results 67% HIV+ women received prophylaxis 12% babies received Cotrimoxazole 17% babies exclusively breastfed 9% babies tested for HIV 26% HIV+ women referred for HIV care

Niger: Reduction in Post-partum Hemorrhage 3

JHU Uganda Performance According to Standards Survey (2001) National sample, 30 health centers 81 indicators grouped into indices; published MOH standards –IMCI assessment: 47% –IMCI treatment: 35 –Malaria treatment: 70 –Antenatal care: 35 –Family Planning: 44 –STI 14 Other examples: –Krause, Borchert, Benzler, Diesfeld: From diagnosis to drug taking: staff compliance with guidelines and patient compliance to prescriptions in Burkina Faso. IJQHC 2000;12:25-30 –Boonstra, Lindbaek, Ngome: Adherence to management guidelines in acute respiratory infections and diarrhea in children under 5 years old in primary health care in Botswana. IJQHC 2005; 17:

M&E Quality Assessments* *Quality Assessments are more detailed evaluations of healthcare processes than M&E (i.e. flow charting). Data Quality Audits Tests of Change Ideas to Test Shared Learning No Improvement Improved Processes Cost Efficiencies | Effectiveness Spread of Improvements

USAID Applying Science to Strengthen and Improve Systems Organized a team and defined aim: increase MUAC screening Trained expert clients to help when nurse not available Using QI to improve the process: One team in Uganda Everyone work harder to do MUAC Analyzed process & developed changes: designate MUAC nurse, integrate with triage station & record in ART card

Uganda - Comparison of Demonstration and Spread Sites Screening for Active TB in HIV+ Patients average of 17,500 HIV+ patients per month in original sites; 5,000 in spread sites CQI interventions Baseline CQI Interventions % of HIV+ patients seen in that month that were screened for active TB, based on Patient register

Research Issues for Process Improvement Very large numbers of standardized health care processes –Example: WHO Ebola Manual on Safe Burials: 154 discrete processes –Health information systems provide minimal coverage of processes –Documented management interventions are uncommon Research related to process improvement is limited –Few studies analyze process improvement efforts –Published literature is focused on outcomes, rarely on processes –A limited health care process literature is strongly focused on external measurement of provider compliance with evidence-based guidelines –Self-reported improvement results are seldom validated Knowledge management in process improvement is poorly- developed